Healthcare Provider Details

I. General information

NPI: 1649688656
Provider Name (Legal Business Name): CHARLIE K. WILSON JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 RAVEN HILL DRIVE
ATCHISON KS
66002
US

IV. Provider business mailing address

800 RAVEN HILL DRIVE
ATCHISON KS
66002
US

V. Phone/Fax

Practice location:
  • Phone: 913-367-2131
  • Fax: 913-674-2023
Mailing address:
  • Phone: 913-367-2131
  • Fax: 913-674-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number557391
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: